| Date: | ____,_____ | Time started: | ____,____ | Length: | ____,____ | Location: | My home | Other's home | Restaurant/Club | In public | Work | Other |
| Nature: | Conversation | Relaxation/Hobby | Work | Meal | Romantic | Celebration | Meeting | Religious activity | Other |
| Language: | Language 1 | Language 2 | Language 3 | Language 4 |
| Initials | Sex | Age | Ethnic | Relation | Relationship: | Casual friend | Close friend | Romantic | Partner | Relative | Co-worker | Stranger | Other | ||
| Person 1 | _____ | _____ | _____ | _____ | _____ | ||||||||||
| Person 2 | _____ | _____ | _____ | _____ | _____ | Ethnicity: | Ethnic 1 | Ethnic 2 | Ethnic 3 | Ethnic 4 | Ethnic 5 | Ethnic 6 | Ethnic 7 | Other | |
| Person 3 | _____ | _____ | _____ | _____ | _____ |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | ||
| Not enjoyable | __ | __ | __ | __ | __ | __ | __ | __ | __ | Enjoyable |
| Not intimate | __ | __ | __ | __ | __ | __ | __ | __ | __ | Intimate |
| Not influential | __ | __ | __ | __ | __ | __ | __ | __ | __ | Influential |
| Not liked | __ | __ | __ | __ | __ | __ | __ | __ | __ | Liked |
| Not respected | __ | __ | __ | __ | __ | __ | __ | __ | __ | Respected |
| Not accepted | __ | __ | __ | __ | __ | __ | __ | __ | __ | Accepted |
| Not free to express ideas | __ | __ | __ | __ | __ | __ | __ | __ | __ | Free to express ideas |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | ||
| Sad | __ | __ | __ | __ | __ | __ | __ | __ | __ | Happy |
| Relaxed | __ | __ | __ | __ | __ | __ | __ | __ | __ | Anxious/Nervous |
| Enthusiastic | __ | __ | __ | __ | __ | __ | __ | __ | __ | Bored |
| Content | __ | __ | __ | __ | __ | __ | __ | __ | __ | Angry |